Accountable Care in Infusion Nursing. Hudson Health Plan. Mission Statement. for all people. INS National Academy of Infusion Therapy

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1 Accountable Care in Infusion Nursing INS National Academy of Infusion Therapy November 14 16, 2014 Atlanta, GA Margaret (Peggy) Leonard, MS, RN-BC, FNP Senior Vice President Clinical Services Hudson Health Plan A proud member of the MVP Healthcare Family November 14, 2014 Hudson Health Plan Not For Profit Medicaid Managed Care Organization (MCO) in New York State s Hudson Valley Founded in 1985 by four community health centers Offers three state-subsidized managed care programs - Medicaid, Family Health Plus and Child Health Plus Served 150,000 members in New York s Hudson Valley (4,000 sq. mi. service area) Joined the MVP Health Care Family of Companies in Combined we serve over 600,000 members Mission Statement To promote and provide access to excellent health services for all people. 1

2 Accountable Care in Infusion Nursing The imperative in accountable care is that all members of the health care team work collaboratively and efficiently to provide the highest quality care and promote effective stewardship. The Centers for Medicare and Medicaid (CMS) identify three critical domains for accountable care organizations: the patient experience, care coordination, and patient safety. Infusion nurses bring valuable knowledge and skills to provide innovative, accountable care. This session presents the essential elements of accountable care and avenues for its application to infusion nursing. Objectives Relate accountable care to improved outcomes Discuss challenges and opportunities for accountable care in infusion nursing Today in health care There is a major healthcare debate Is the healthcare system broken? If yes, how can it be fixed. President continues to convene expert panels and develop new partnerships Is INS at the table? 2

3 Today in health care Legislators are looking for: Solutions - Is INS part of the solution? Input from all stakeholders Are you giving input? Support from the populous Are you actively supporting the measures you believe in? Critical Issues in Health Care Care is complex Care is uncoordinated Information is often not available to those who need it, when they need it Results, pts. often don t get care they need or do get care they don t need Costs are out of control Pts. believe that someone is actually coordinating their care 8 Physical and Behavioral Health Co-Morbidities Depression and/or anxiety will be present in 15%-60% of persons with chronic medical illness. Psychiatric illness will be present in 19% of persons in outpatient medical settings, and in 40% of persons in inpatient medical settings. A single medical illness will be present in persons with a Serious Mental Illness (SMI) 75% of the time, and 50% will have multiple medical illnesses. Communication among physical health and behavioral health practitioners is typically very limited, and occurs much less frequently than among medical specialties. 9 3

4 Health Care Reform Legislation The Patient Protection and Affordable Care Act offers infusion nursing many opportunities. Are you prepared? Health Care Reform Industry impacts Title III Improving the Quality and Efficiency of Health Care This section provides incentives for doctors, and hospitals that improve quality while providing for better coordination that helps to reduce harmful medical errors and healthcare-acquired infections. Title IV Prevention of Chronic Disease and Improving Public Health This section improves data collection and analysis, facilitates better data sharing, and requires the development of standards for the collection of data regarding the nation s health and the performance of the nation s health care, including health disparities. These two sections in the health care reform legislation focus on the core areas of interest for patient centered organizations. *Care Coordination *Disease Management *Case management *Transition of Care Title III Care coordination /Case management Improving the Quality and Efficiency of Health Care Create processes for the development of quality measures involving input from multiple stakeholders and for selecting quality measures to be used in reporting to and payment under federal health programs Establishing community health teams to support the patient-centered medical home Creates a program to establish and fund the development of community health teams to support the development of medical homes by increasing access to comprehensive, community based coordinated care Program to facilitate shared decision making This section calls for the establishment of independent standards for patient decision aids as well as a program to develop and update those standards. It creates a grant program to establish Shared Decision Making Resource Centers. 4

5 Hospital Readmissions and Transition of Care Title III (Continued) Hospital readmissions reduction program This provision would adjust payments for hospitals paid under the inpatient prospective payment system based on the dollar value of each hospital s percentage of potentially preventable Medicare readmissions for the three conditions with risk adjusted readmission measures that are currently endorsed by the National Quality Forum Provide Secretary of Health and Human Services authority to expand the policy to additional conditions in future years and directs the Secretary to calculate and make publicly available information on all patient hospital readmission rates for certain conditions. Community-based Care Transitions Program Provides funding to hospitals and community-based entities that furnish evidence-based care transition services to Medicare beneficiaries at high risk for readmission Disease Management and Public Health Title IV Prevention of Chronic Disease and Improving Public Health Health and Human Services will develop a national quality improvement strategy that includes priorities to improve the delivery of health care services, patient health outcomes, and population health. Effective date, January 1, 2011 Establish a Prevention and Public Health Fund for prevention, wellness, and public health activities including prevention research and health screenings, the Education and Outreach Campaign for preventive benefits, and immunization programs. Appropriate $7 billion in funding for fiscal years 2010 through 2015 and $2 billion for each fiscal year after Effective fiscal year 2010 Administrative Streamlines and Cost Containment In care coordination, case management, transition of care and disease management all work within the health care administrative system. Below are some administrative reforms to streamline the health care administrative process Simplify health insurance administration by adopting a single set of operating rules for eligibility verification and claims status (rules adopted July 1, 2011; effective January 1, 2013) Electronic funds transfers and health care payment and remittance (rules adopted July 1, 2012; effective January 1, 2014) Health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization (rules adopted July 1, 2014; effective January 1, 2016). 5

6 Care Coordination and Case Management within Medicare and Medicaid Establish a national Medicare pilot program to develop and evaluate paying a bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care that begins three days prior to a hospitalization and spans 30 days following discharge. Effective January 1, 2011 Improve care coordination for dual eligibles by creating a new office within the Centers for Medicare and Medicaid services, the Federal Coordinated Health Care Office, to more effectively integrate Medicare and Medicaid benefits and improve coordination between the federal government and states in order to improve access to and quality of care and services for dual eligibles. Effective April 1, 2010 National Initiatives National Priorities Partnership Six priorities National Quality Forum Care Coordination Steering Committee National Committee for Quality Assurance Medical Home Accreditation National Transitions of Care Coalition Case Management Society of America Case Management Model Act 2010 Standards of Practice Accountable Care Act: Current Trends in the Provision of Healthcare Services 6

7 Integrated Care Model Health Home A Health Home is a care management service model whereby all of an individual's caregivers communicate with one another so that all of a patient's needs are addressed in a comprehensive manner. This is done primarily through one designated "care manager" who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital. Health records are shared (either electronically or paper) among providers so that services are not duplicated or neglected. The health home services are provided through a network of organizations providers, health plans and community-based organizations. When all the services are considered collectively they become a virtual "Health Home." Infusion Nurses Society Has so Much to Offer Learning Sharing Discovering Innovating Are you taking advantage of INS membership? o Do you use the INS Knowledge Center 7

8 Infusion Nurses Society Are you certified? Do you know and practice by your Infusion Nursing Standards of Practice? Are you keeping up to date on what is going on in your specialty through reading: Journal of Infusion Nursing INS Newsletter INS Connection INS Newsbrief Infusion Nurses Where Do We Go From Here? Be Smart About Our Priorities Be Proactive About Our Agenda Be Realistic About Our Expectations Secure Seats at the Tables NQF CMS TEP US Roundtable URAC NCQA 8

9 How can we influence the process Continue to be: politically active at the table part of collaboratives active in our grassroots efforts knowledgeable about the issues and keep our members informed the change makers the movers and shakers In short We have to be politically active. Infusion Nurses Society Have so Much to Offer Learning Sharing Discovering Innovating Take advantage of what INS has to offer because - 9

10 We can make a difference Thank You! References Affordable Care Act: Infusion Nurses Society: Leonard, M., Case Management Matters, Professional Case Management, Volume 19/Number 5. (September 2014) New York State Department of Health: 10

11 Margaret Leonard MS, RN-BC, FNP Senior Vice President for Clinical Services Hudson Health Plan A proud member of the MVP Health Care Family of Companies 303 S. Broadway, Suite 321 Tarrytown, NY mleonard@hudsonhealthplan.org 11